Prescription Opioid Use and Opioid-Related Overdose Death —

TN, 2009–2010

Jane A.G. Baumblatt, MD

Centers for Disease Control and Prevention

Epidemic Intelligence Service OfficerTennessee Department of Health

Office of Surveillance, Epidemiology, and Laboratory ServicesScientific Education and Professional Development Program Office

Background

Increase in prescription opioid use since 1990s

Opioids are powerful painkillers Action on central nervous system

analgesia Action on respiratory center decrease

respiration

Increase in prescription opioid-related drug overdose and death

Opioid Sales,Treatment Admissions and Opioid-Related Overdose Death Rates —

United States, 1999–2010

National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

1

2

3

4

5

6

7

8

Opioid Sales KG/10,000

Opioid Deaths/100,000

Opioid Treatment Admissions/10,000

Rate

4

Rates of Opioid-Related Overdose Death Tennessee and United States,

1999–2010

Source: Tennessee Department of Health – Vital Statistics, NCHS Data Brief,

Rate

per

10

0,0

00

p

op

ula

tion

Opioid Use Definitions

Misuse Taking opioids in greater amount / frequency than

prescribed

Abuse Opioid drug use with resulting harm to health or

social functioning

Non medical use Opioid use without a prescription or for the

feeling it causes

Diversion Selling, trading or giving away opioids to others

Impact of Opioid Use — United States, 2010

1OD death

10Admissions for opioid abuse

26ED visits for abuse

108Report abuse or dependence

733 Report non medical use of opioids

Source: Treatment Exposure Data, DAWN data, National Survey on Drug Use and Health Data

Prescription Drug Monitoring Programs, 2012

Tennessee Controlled Substances Monitoring Program (TNCSMP)

Established 2006

Monitor prescribing of controlled substances—drugs illegal to use except with prescription

Drug Enforcement Agency (DEA) Schedule II–V

Provider participation was voluntary

Tennessee Prescription Safety Act

Established 2012

Purpose is to identify and target patients at risk of abuse

Requires provider and pharmacy participation in TNCSMP

Education of medical community important in implementation

TNCSMP Algorithm

Provider OpioidPrescription

Tennessee

Pharmacy

TNCSMP

database

Actual Output

Study Objectives

1. Describe epidemiology of prescription opioid use

2. Describe patterns of high-risk opioid use

3. Assess risk of unintentional opioid-related overdose death

Descriptive Analysis, 2007–2011

Tennessee Controlled Substances Monitoring Program data

Inclusion criteria Dispensed 2007–2011 Tennessee residents Tennessee providers

Overview of TNCSMP Data —TN, 2007–2011

37.1 million Opioid prescriptions

5.2 millionPatients

20,489Providers

2419 Pharmacies

2011 TN

Population 6.4 million

Rates of Male and Female Patients Prescribed Opioids per 100 Population by Year, 2007–2011

Rate

per

10

0

pop

ula

tion

Opioid Prescription Rates by County—TN, 2007

Opioid Prescription Rates by County—TN, 2008

Opioid Prescription Rates by County—TN, 2009

Opioid Prescription Rates by County—TN, 2010

Opioid Prescription Rates by County—TN, 2011

Number of Opioid Prescriptions by Type of Opioid —TN, 2007–2011

Op

ioid

Ty

pe

Nu

mb

er

of

Pati

en

ts

Number of Prescriptions

Number of Patients by Opioid Prescriptions Received, 2007‒2011

Study Objectives

1. Describe epidemiology of prescription opioid use

2. Describe patterns of high-risk opioid use

3. Assess risk of unintentional opioid analgesic-related overdose death

Definitions of High Risk Factors

High-risk number of providers ≥4 providers in a year

High-risk number of pharmacies ≥4 pharmacies in a year

High dosage >100 morphine milligram equivalents (MME)

per day average for year

Number of Patients by Number of Providers 2007‒2011

Nu

mb

er

of

Pati

en

ts

Number of Providers

Patients with a High-Risk Number of Providers

Nu

mb

er

of

Pati

en

ts

Number of Providers

Number of Patients by Number of Pharmacies 2007‒2011

Nu

mb

er

of

Pati

en

ts

Number of Pharmacies

Patients with a High-Risk Number of Pharmacies

Nu

mb

er

of

Pati

en

ts

Number of Pharmacies

Number of Patients with High-Risk Dosage

Year

Nu

mb

er

of

Pati

en

ts

Study Objectives

1. Describe epidemiology of prescription opioid use

2. Describe patterns of high-risk opioid use

3. Assess risk of unintentional opioid-related overdose death

Matched Case Control Study

Case Unintentional opioid-related overdose death Aged >10 years, with Rx within 1 year of death Tennessee vital records death certificate data,

2009–2010

Control 20 live patients per case Matching sex, age, 1 year exposure periods ≥ 1 Rx in TNCSMP during study period

Demographics of Decedents in TNCSMP2009–2010

(N=592)Age, years

Median

43

Range 18–92

Males, no. (%) 330 (56)

Race, no. (%)

White

576 (97)

Black 14 (2.7)

Risk of Unintentional Opioid-related Overdose Death by Patient Risk Factors

Risk factor

CasesN=592

No. (%)

Controls N=11,840

No. (%)

AORs 95% Confidence Interval

≥ 4 Providers 227 (38) 513 ( 4 ) 6.5 5.1–8.4

≥ 4Pharmacies

145 (24) 196 ( 2 ) 6.0 4.4–8.3

High dosage use

140 (24) 172 ( 1 ) 11.2 8.3–15.1

Association of Number of Providers or Pharmacies with Risk of Opioid-Related

Overdose Death

Association of Opioid Dosage with Risk of Opioid-Related Overdose Death

Od

ds R

ati

o

Mean Daily Dosage in Morphine Milligram Equivalents

Association Of Type of Opioid with Risk of Opioid-Related Overdose Death, 2009–

2010

Study Summary

Risk factor% of All Patients

% of Decedents

High-risk number of providers

8.3 38

High-risk number of pharmacies

2.7 24

High-risk dosage 1.9 24

Discussion

Opioid use statewide problem in TN

Female rate > male rate

Opioid related overdose deaths associated with high risk prescribing patterns

Diversion a real concern

Increased monitoring in Tennessee may lead to increased activity in bordering states

Limitations

Not all prescriptions are captured Active duty military and VA facilities Hospital and out of state dispensing

Matching on sex and age, unable to evaluate these variables

Dispensing patterns proxy for use, unable to evaluate forms of use

Conclusions

Prescription opioid misuse major public health problem

High risk use increasing and associated with increased risk of death

TNCSMP invaluable tool in describing problem of prescription misuse

Recommendations

Analyze TNCSMP data regularly Evaluate trends Monitor for aberrant activity

Monitor provider and pharmacy compliance with Safety Act of 2012

Educate key stakeholders about opioid misuse and abuse; providers, pharmacists, patients

Tennessee Department of HealthCaleb Wiedeman, MPHJohn R. Dunn, DVM, PhDTim F. Jones, MD

Vanderbilt University School of Medicine William Schaffner, MD

Centers for Disease Control and Prevention Leonard J. Paulozzi, MD, MPHEdward C. Weiss, MD, MPH

The findings and conclusions in this report are those of the authors and do not

necessarily represent the official position of the Centers for Disease Control

and Prevention.Office of Surveillance, Epidemiology, and Laboratory ServicesScientific Education and Professional Development Program Office

Acknowledgments

Office of Surveillance, Epidemiology, and Laboratory Services

Scientific Education and Professional Development Program Office

Thank You

Questions?

Unintentional Overdose Death Rates per 100,000 Population by Age Group — TN,

2009–2010

Rate

per

100,0

00

pop

ula

tion

Age group in Years

Numbers of Cases and Controls with Risk Factors

No Risk Factors

One Risk Factor

Any Two Risk Factors

All Three Risk Factors

Cases 269 (45%)169

(29%) 119 (20%) 35 (6%)

Controls11131 (94%) 549 (5%) 148 (1%) 12 (0.1%)

Year # UniquePatients  

# Unique (Opioid) Prescriptions

# UniquePharmacies 

# Unique Providers

2007       

1,761,168           

6,272,409  1,760  14,828

2008       

1,913,416              

7,176,542  1,801   15,525

2009       

1,956,246              

7,460,239  1,827   16,316

2010       

1,959,923              

7,739,698  1,885  17,054

2011       

2,024,551            

8,449,105  1,919  17,555

Total Numbers of “The Four Ps” in TNCSMP — TN, 2007–2011

Rate of Prescriptions per 100 population by Health Region

CHR ETR JMR KKR MCR MSR NDR NER SCR SER SUL UCR WTR0

20

40

60

80

100

120

140

160

180

200

20072008200920102011

Unintentional Overdose Death Rates per 100,000 Population by Region — TN,

2009–2010

Region

Rate

per

100,0

00

pop

ula

tion